Chief Complaint: Cannot sleep for ten years
Western Diagnosis: Chronic Insomnia
Medical History: Patient is a 44 year old female. She has a history of seeing various physicians without adequate results. She has no history of smoking, alcohol or drug abuse. She tends to her garden at home but does no cardiovascular exercises.
Questioning exam: Patients shows signs of depression, stress, and fatigue. Bowel movement and urine are normal.
Pulse exam: Pulses CUN and GUAN are thin and weak, showing that the heart and spleen are deficient.
Tongue exam: Tongue is pale and pink with a thin white coating showing a blood deficiency. Her face appears pale and tired.
OM Diagnosis: Her interrupted sleep patterns appear to be the result of heart and blood deficiency. With a heart blood deficiency, this sets up malnourishment of the brain thus setting up insomnia. This results in further depression and stress. As a result of this her spleen is not fully functional. This creates further fatigue. This results in a pale tongue, pale face and thin and weak pulse.
Treatment Principle: Basic treatment is to stimulate the heart and spleen in order to tonify the Qi and blood. This in turn soothes the mind.
Point Prescription: In order to tonify the heart and spleen I used the following points. zu san li(both sides), Quchi. For soothing the mind I used Shen men (both sides) and shen men in both ears. She came in for treatment once a week for 4 weeks.
Herbal Formula: Gui Pi Tang(Ginsing and Longan Combination). 5 packages a week in solution. Drink twice a day for one month.
Lifestyle Prescription: Increase her cardiovascular exercise to 20 minutes of walking 3 to 5 times a week. Avoid spicy food. Learn the process of meditation.
Results: Patient showed improvement in one week. After 4 treatment weeks insomnia is relieved.
Synopsis: Patient was encouraged to make follow visits at least once a month to extend results, monitor her depression and stress.
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